Basic Information
| Provider Information | |||||||||
| NPI: | 1245287515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTHARI | ||||||||
| FirstName: | MADHUBALA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 TOWN CENTER DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201905905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304550374 | ||||||||
| FaxNumber: | 3304552101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 TOWN CENTER DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201905905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304550374 | ||||||||
| FaxNumber: | 3304552101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 0101263835 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7610021 | 05 | OH | MEDICAID |